ANNUAL REPORT FOR PROGRAMS IN NURSING

Ancilla College 1 Associate Degree Indiana State Board of Nursing 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2043 Fax: (317) 233-4236 Website: www.pla.in.gov Email: pla2@pla.in.gov ANNUAL REPORT FOR PROGRAMS IN NURSING Governor Mitchell E. Daniels, Jr. Guidelines: An Annual Report, prepared and submitted by the faculty of the school of nursing, will provide the Indiana State Board of Nursing with a clear picture of how the nursing program is currently operating and its compliance with the regulations governing the professional and/or practical nurse education program(s) in the State of Indiana. The Annual Report is intended to inform the Education Subcommittee and the Indiana State Board of Nursing of program operations during the academic reporting year. This information will be posted on the Board s website and will be available for public viewing. Purpose: To provide a mechanism to provide consumers with information regarding nursing programs in Indiana and monitor complaints essential to the maintenance of a quality nursing education program. Directions: To complete the Annual Report form attached, use data from your academic reporting year unless otherwise indicated. An example of an academic reporting year may be: August 1, 2011 through July 31, 2012. Academic reporting years may vary among institutions based on a number of factors including budget year, type of program delivery system, etc. Once your program specifies its academic reporting year, the program must utilize this same date range for each consecutive academic reporting year to insure no gaps in reporting. You must complete a SEPARATE report for each PN, ASN and BSN program. This form is due to the Indiana Professional Licensing Agency by the close of business on October 1st each year. The form must be electronically submitted with the original signature of the Dean or Director to: PLA2@PLA.IN.GOV. Please place in the subject line Annual Report (Insert School Name) (Insert Type of Program) (Insert Academic Reporting Year). For example, Annual Report ABC School of Nursing ASN Program 2011. The Board may also request your most recent school catalog, student handbook, nursing school brochures or other documentation as it sees fit. It is the program s responsibility to keep these documents on file and to provide them to the Board in a timely manner if requested. Indicate Type of Nursing Program for this Report: PN ASN X BSN Dates of Academic Reporting Year: _1 January 2011 to 31 December 2011 (Date/Month/Year) to (Date/Month/Year) Name of School of Nursing: _Ancilla College

Address: PO Box 1, 9601 Union Road Donaldson, IN 46513 Dean/Director of Nursing Program Name and Credentials: _Ann Fitzgerald, PhD(C), MSN, CNE FNP Title:_ Director, Division of Nursing E mail:_ ann.fitzgerald@ancilla.edu Nursing Program Phone #:_574-936-8898 Fax:_574-935-1773 Website Address: ancilla.edu Social Media Information Specific to the SON Program (Twitter, Facebook, etc.):_facebook Please indicate last date of NLNAC or CCNE accreditation visit, if applicable, and attach the outcome and findings of the visit:_ 2006_NLNAC Visit at the end of this report. If you are not accredited by NLNAC or CCNE where are you at in the process? _Reapplicaiton has not begun again: plan to reapply after completed curriculum revision slated for fall 2013. SECTION 1: ADMINISTRATION Using an X indicate whether you have made any of the following changes during the preceding academic year. For all yes responses you must attach an explanation or description. 1) Change in ownership, legal status or form of control Yes No_ X 2) Change in mission or program objectives Yes No_ X 3) Change in credentials of Dean or Director Yes No_ X 4) Change in Dean or Director Yes No _X 5) Change in the responsibilities of Dean or Director Yes No _X 6) Change in program resources/facilities Yes No _X 7) Does the program have adequate library resources? Yes _X No 8) Change in clinical facilities or agencies used (list both Yes No _X additions and deletions on attachment) 9) Major changes in curriculum (list if positive response) Yes No_ X SECTION 2: PROGRAM 1A.) How would you characterize your program s performance on the NCLEX for the most recent academic year as compared to previous years? Increasing Stable Declining _X

1B.) If you identified your performance as declining, what steps is the program taking to address this issue? Created and used a custom designed HESI exam for NURS 210 Lifespan I, increased the weight of each HESI specialty exam to approximately 30% of overall test grade for each course, increased required HESI exit exam to 80% and mandated a minimum of 20 hours of personal tutor time for final attempt at HESI exit exam. 2A.) Do you require students to pass a standardized comprehensive exam before taking the NCLEX? Yes X No 2B.) If not, explain how you assess student readiness for the NCLEX. 2C.) If so, which exam(s) do you require? _ Use all HESI exams: Admission Assessment (entrance requirement), HESI specialty (requirement during program), Exit (requirement for exit from program)_ 2D.) When in the program are comprehensive exams taken: Upon Completion X As part of a course X Ties to progression or thru curriculum X 2E.) If taken as part of a course, please identify course(s):_ NURS 110 Fundamentals of Nursing, NURS 210 Lifespan I, NURS 260 Pharmacology, NURS 211 Lifespan II, NURS 250 Maternal Child Nursing, NURS 255 Psychiatric Mental Health Nursing. 3.) Describe any challenges/parameters on the capacity of your program below: A. Faculty recruitment/retention:_ Difficult to recruit MSN prepared faculty with teaching experience. B. Availability of clinical placements:_ Rural area, clinical placements not an issue. C. Other programmatic concerns (library resources, skills lab, sim lab, etc.):_computer and internet access. 4.) At what point does your program conduct a criminal background check on students? _After admission to Nursing program. 5.) At what point and in what manner are students apprised of the criminal background check for your program?_ Upon receipt of a positive result, students are emailed and phoned, and must meet with the Director and clinical facility liaison. SECTION 3: STUDENT INFORMATION 1.) Total number of students admitted in academic reporting year: Summer_20 LPN to ASN Bridge Fall 40 ASN Spring 0 2.) Total number of graduates in academic reporting year: Summer 6 Fall 4 Spring 28

3.) Please attach a brief description of all complaints about the program, and include how they were addressed or resolved. For the purposes of illustration only, the CCNE definition of complaint is included at the end of the report. (1) Parent c/o grading procedures Board visit specific grading verbiage removed from Student Handbook. (2) Student c/o regarding increased required HESI exit to 80% - student misunderstanding of rules; explanation of same ended c/o process. 4.) Indicate the type of program delivery system: Semesters X Quarters Other (specify): SECTION 4: FACULTY INFORMATION A. Provide the following information for all faculty new to your program in the academic reporting year (attach additional pages if necessary): Faculty Name: Indiana License Number: Full or Part Time: Elizabeth Bailey 28154538A Part-time Date of Appointment: 8/1/2011 Highest Degree: Responsibilities: BSN; MSN in progress OB clinical; Lifespan I clinicals Faculty Name: Indiana License Number: Full or Part Time: Date of Appointment: Highest Degree: Responsibilities: Faculty Name: Indiana License Number: Full or Part Time:

Date of Appointment: Highest Degree: Responsibilities: B. Total faculty teaching in your program in the academic reporting year: 1. Number of full time faculty: 4 2. Number of part time faculty: 2 3. Number of full time clinical faculty: 4 4. Number of part time clinical faculty: 2 5. Number of adjunct faculty: 0 C. Faculty education, by highest degree only: 1. Number with an earned doctoral degree: 0 2. Number with master s degree in nursing: 4 3. Number with baccalaureate degree in nursing: 2 4. Other credential(s). Please specify type and number: CNE (3), FNP (2), PhD(c) - 1_ D. Given this information, does your program meet the criteria outlined in 848 IAC 1-2-13? Yes X No E. Please attach the following documents to the Annual Report in compliance with 848 IAC 1-2-23: 1. A list of faculty no longer employed by the institution since the last Annual Report; 2. An organizational chart for the nursing program and the parent institution.

I hereby attest that the information given in this Annual Report is true and complete to the best of my knowledge. This form must be signed by the Dean or Director. No stamps or delegation of signature will be accepted. 9/28/12 Signature of Dean/Director of Nursing Program Date Ann Fitzgerald Printed Name of Dean/Director of Nursing Program Please note: Your comments and suggestions are welcomed by the Board. Please feel free to attach these to your report.

Definitions from CCNE: Potential Complainants A complaint regarding an accredited program may be submitted by any individual who is directly affected by the actions or policies of the program. This may include students, faculty, staff, administrators, nurses, patients, employees, or the public. Guidelines for the Complainant The CCNE Board considers formal requests for implementation of the complaint process provided that the complainant: a) illustrates the full nature of the complaint in writing, describing how CCNE standards or procedures have been violated, and b) indicates his/her willingness to allow CCNE to notify the program and the parent institution of the exact nature of the complaint, including the identity of the originator of the complaint. The Board may take whatever action it deems appropriate regarding verbal complaints, complaints that are submitted anonymously, or complaints in which the complainant has not given consent to being identified. Faculty No Longer Employed since the Last Annual Report Joyce Palmateer Janeen Berndt

SITE VISITORS REPORT Ancilla College Plymouth, Indiana Program Type: Associage Degree Purpose of Visit: Initial Accreditation Date of Visit: February 21-23, 2006 GENERAL INFORMATION Nursing Education Unit Ancilla College Department of Nursing 9601 Union Road Plymouth, IN 46563 Nurse Administrator Ann Fitzgerald, MSN, RN, APRN Director of Nursing & Health Sciences Name of Governing Organization Ancilla College 9601 Union Road Plymouth, IN 46563 Chief Executive Officer Neil Thorburn, PhD Interim President Telephone: (574) 936-8898 Ext. 379 Fax: (574) 935-1773 E-mail: ann.fitzgerald@ancilla.edu State Board of Nursing Approval Status Indiana State Board of Nursing Date of Last Review: Survey visit: February 27, 2004 Action: Initial accreditation was granted. July 20, 2005 2 nd survey visit board approved survey visit. 3 rd survey visit will be after 1 st graduating class and will determine if program is placed on full program accreditation.

Accreditation Status: Program NLNAC Date of Last Review: Action: Non applicable. Accreditation Status: Governing Organization North Central Association of Colleges and Schools Commission on Institution of Higher Education Date of Last Review: 08/12/2005 Action: Progress Report 09/01/2006 A report on assessment of student learning SITE VISIT INFORMATION I. INTRODUCTION Program Evaluator Team: Chairperson Kathy Hankel, MS, RN Director Department of Nursing Genesee Community College One College Road Batavia, NY 14020-9704 Telephone: (585) 345-6837 Ext. 6367 Fax: (585) 343-4334 E-mail: kmhankel@genesee.edu Member Margaret Mary West, DNSc, RN Program Coordinator Associate of Science in Nursing, RN-BSN/MSN Thomas Jefferson University Nursing Education Center Danville, PA 17822-0403 Telephone: (570) 214-9215 Fax: (570) 271-5657 E-mail: mmwest@geisinger.edu NLNAC Criteria Used: 2002 Program Demographics: Year Nursing Program Established: Fall 2004 1 st Group 40 Students Faculty: Number of Faculty teaching Full-time in the Associage Degree nursing program: 5 Number of Faculty teaching Part-time in the Associage Degree nursing program: 4 Students: Total enrollment: ASSOCIAT DEGREE 66 Full-time: 66 Part-time: _0 Length of Program: Associate Degree: 2 semesters prerequisites prior to acceptance (if FT), 4 semesters in nursing program 72 credits total Third Party Comment: The nursing unit had a reasonable process for soliciting third party comments. The methods used to announce the accreditation visit to the program s communities of interest

were: college website, announced at advisory committee meeting, and posted announcements around campus on bulletin boards. Third party comments were received in response to the solicitation. Representatives from clinical agencies were in attendance (total 16.) Favorable responses were received. Comments include college has good community reputation, expect same of the nursing program, Students are professional, courteous, look forward to hiring the graduates. Persons/Groups Interviewed: Ann Fitzgerald, MSN, RN APRN, Director, Division of Nursing and Health Sciences Neil Thorburn, PhD, Interim President Sharon Blubaugh, AB, MAT, Interim Academic Dean/Registrar Support Staff Meeting Mike Brown, MBA BS, Executive Director of Finance and Administration Michael Schmaltz, AAS, Financial Aid Director Erin Whittmeyer, MBA, Admissions Director Sharon Blubaugh, AB, MAT, Registrar Reverend Dr. Sam Boys, BA, MDiv, DMin, Coordinator of Pastoral Ministry Sr. Carleen Wrasman, PHJC, MSEd, BSEd, Mission Integration, Instructor of Religion Carol Saft, MA BA, Director of Academic Assessment and Institutional Research Nursing Lab Jennifer Jackson 2006 Nursing Student Meet with Nursing Students Kathleen David Students were selected by the program to represent the student group at the meeting. Only these students were emailed an invitation to attend from the program. Class of 2007 N=3 Class of 2006 N=3 Glenda Bockman, MLS, BS, Librarian Open Forum Bridget Dudash, MSN, RN, Saint Joseph Regional Medical Center, Inc., Plymouth Campus Diane Endres, Assistant Registrar, Ancilla College Carol Meadows, RN, Assistant Director of Nurses, Catherine Kasper Life Center Janet Stone, LPN, MDS Coordinator, Catherine Kasper Life Center Linda Webb, BSN, MBA, RN, CNE, Pulaski Memorial Hospital Lori Retske, BSN, RN, Director of Nurses, Michiana Behavioral Health Center Barb Gouker, CCM, RN, Nurse Manager, Michiana Behavioral Health Center Marian Long, RN, Nurse Manager, Michiana Behavioral Health Center Erin Whittmeyer, MBA, Director of Admissions, Ancilla College Ioana Mateica, Nurse Student, Ancilla College Rachel Moody, MS, CNS, RN, LaPorte Hospital Tammy Awald, MS, RN, Vice President of Patient Care, St. Joseph Regional Medical Center, Inc., Plymouth Campus Patricia Stickley, RN, Educational Coordinator, Catherine Kasper Life Center Sr. Judian Breitenbach, PHJC, RN, MSN, Namaste' Center for Holistic Education Nursing Faculty Meeting Janeen Berndt, MSN, RN, APNP, Instructor - Fundamentals, Life Span I, Pharmacology Jody Rodgers, CNOR, RN, Instructor - Fundamentals, Life Span I, Pharmacology Judy Bachelder, MSN RN, Instructor - Maternal/Child Nursing

Kelly Clark, MSN, RN, FNP, Instructor - Psychiatric Nursing Beth Taylor, MSN, RN, FNP-c, Adjunct Faculty - Life Span II Carol Swanson, BA, Nursing Administrative Assistant Sr. Magdala Oswald, PHJC Sr. Damien McNamera, PHJC Documents Reviewed: Catalogs/Handbooks/Manuals Ancilla College Course Catalog - 2004-2006 and rough draft 2006-2007 Ancilla College Faculty Handbook 1995 and 2005 Ancilla College Student Handbook 2005-2006 Ancilla College Advising Handbook Ancilla College Safety and Security Folder Enrollment Report, Fall 2005 Ancilla College Credit Hours, Fall 2004 Ancilla College Head Count, 1993-2004 Ancilla College Faculty and College Organizational Charts Ancilla College Standing Committees 2005-2006 Ancilla College Environment and Services Survey Ancilla College Assessment results of Environment and Services Survey, spring 2005. Ancilla College Library Book and Periodicals list Ancilla College Default Rates and Financial Aid Student info packet External Constituencies Nursing and Governing Organization Documents Nursing Unit Minutes Course Materials Pri-Med Updates Conference Folders 2004 Updates - Indianapolis, IN 2005 Updates - Cleveland, OH Boot Camp and Beyond: Best Practices for Nurse Educators Folder Teaching Professor Folder AED Folder Marshall County Quickfacts (US Census Bureau, 2000) Health Professions Bureau March. 04 Initial Accreditation Granted September 2005 Continued Initial Accreditation Higher Learning Commission Affiliation Status Indiana State Licensure Statues and Rules, 2005 Edition Indiana State Board of Nursing Annual Report for Programs of Nursing 2004 and 2005 Report of Survey Visit 2004 and 2005 Success Center information for Nursing Program Placement Testing Financial Aid Policy on Maintenance of Student Financial Records Nursing and Governing Organization Documents Nursing Policies and Procedures Nursing Student Handbook, 2005-2006, January 2006 version Nursing Course/Clinical Evaluation Forms Course/Instructor Evaluation

Clinical Instructor Evaluation Clinical Facility Evaluation Instructor Evaluation of Clinical Facility Post-Graduate Evaluation Nursing Course/Clinical Evaluation Forms Facility Evaluation of Clinical Rotations Evaluation Data 2004-2005 and 2005-2006 Lecture Evaluation of Instructors Student Evaluation of Clinical Instructors Student Evaluation of Clinical Facility Facility Evaluation of Clinical Rotations Instructor Evaluation of Clinical Facility Nursing Faculty Professional Portfolios Janeen Berndt, MSN, RN, APNP Jody Rodgers, RN, CNOR Ann Fitzgerald, MSN, RN, APRN Pat Bawcum, MSN, RN Kelly Clark, MSN, RN, FNP Beth Taylor, MSN, RN, FNPc Joyce McMahon Palmateer, MSN, RN, FNP Nursing Faculty Resumes and files as above plus: Judy Bachelder, MSN, RN, Lisa Stults, MSN, RN, FNP Sclerotherapy for Varicose Veins July, 2004 Ann Fitzgerald, Angela Turner-Brown, Janette Roddel, and Tamara Sheilds Ancilla College Admission Information Packet for Prospective Students Educational Resources Inc. Information Packet Student Files Class of 2007 N=4 Class of 2006 N=4 Expected Competencies of Associate, Baccalaureate and Advanced Prepared Nurse Providers by the Indiana Deans and Directors and the Indiana Organization of Nurse Executives Job Descriptions: Maternal/Child, Psychiatric/Mental Health, Medical Surgical, Full and Part-time Nursing Faculty; Director, Division of Nursing and Health Sciences; Administrative Assistant Nursing Faculty Interview Sheet Sample Contracts for full and part-time instructors Employee Evaluations: Annual Performance Evaluation, Faculty self-evaluation form, Faculty record of Professional Development, Evaluation of Division Chair, Division Chair evaluation of faculty. Systematic Plan for Program Evaluation and Assessment Outcomes Sample of Clinical Affiliation Agreement Division of Nursing List of Clinical Affiliates Agency Affiliation Agreements Hospitals Saint Joseph's Regional Medical Center, Inc. Plymouth Campus LaPorte Hospital and Health Systems Pulaski Memorial Starke Memorial Woodlawn Hospital

Behavioral Healthcare Center, Plymouth Campus Nursing Homes Catherine Kasper Life Center Countryside Place Miller's Merry Manor - Plymouth Miller's Merry Manor - Walkerton Wintersong Village Nursing Unit Minutes Nursing Department Meetings (2004-2006) Nursing Faculty Organization Meeting Minutes Curriculum Committee Meeting Minutes Dean Meeting Minutes Ancilla College Nurses Association Minutes 2004-2006 Nursing Advisory Board Minutes Ancilla College Nursing Support of Academic Core Values Ancilla College Nursing Support of General Education Requirements Correlation of Ancilla College Core Values to Division of Nursing Core Concepts, Portfolio Criteria and Outcome Criteria Course Materials All Nursing Course Syllabi may be found in Criterion 12 folder All Nursing Course Calendars for Spring 2006: exception of NR 110 Fundamentals Fall 2005 NR 110 Fundamentals - Care plans, Journals, and/or Assessments - Fall, 2005 N=2 Exams - Fall, 2005 - Exams 1 and 2 Final Clinical Evaluation Form Plan of action for student success N=1 Course Assessment Reporting Form Fall, 2005 NR 210 Lifespan I Care plans, Journals, and/or Assessments Spring, 2006 N=4 Care Plan Rubric Research Paper Guidelines Clinical Guidelines - LaPorte Hospital & Pulaski Memorial Hospital Midterm Clinical Evaluation Rotation Schedule Clinical Checklist Exams - Spring, 2006 - Exam 1 NR 260 Pharmacology Patient Education Paper Guidelines Exams - Exam 1 NR 211 Lifespan II Care plan Guidelines Clinical Journal Guidelines Clinical Journal Rubric

Mid-term Clinical Evaluation Weekly Clinical Assignments for Fall, 2005; spring 2006 Journal Focus - Spring 2006 Care Plan Rubric Examples of weekly study-guide handouts provided to students. Assessment Tool Care plans, Journals, and/or Assessments - Spring, 2006 N=4 Exams - Spring, 2006 Exam 1 NR 240 Nursing Ethics, History, Issues & Trends Exams - Fall, 2005 - Midterm Exam NR 250 Maternal Child Nursing Care plans, Journals, and/or Assessments - Spring, 2006 N=7 Purpose of Course Record of Student Observation Hours Journals Guidelines for teaching presentation and rubric; critique of teaching presentation tool Newborn and Post partum care plan guides and rubric Guidelines for Pediatric and Maternal child Nursing process paper Guidelines for Extra Credit Course points log Mid term Remediation plan Exams - Fall, 2005 - Exam 4 NR 255 Psychiatric Nursing Assessment tool Care Plan Rubric Role Play video requirements Mid-term advisory report Clinical Journal Guidelines Clinical Guidelines Psychiatric Mental Health Nursing Care plans, Journals, and/or Assessments - Fall, 2005 Kristy Fort, Lacey Lacefield, Kristine Ross - Spring, 2006 Elizabeth Cleveland Exams - Spring, 2006 - Exam 1 II. EVALUATION OF THE STANDARDS AND CRITERIA Mission and Governance Standard: There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. Criteria: 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. 2. Faculty, administrators, and students participate in governance as defined by the governing organization and nursing education unit.

3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. 4. Polices of the nursing education unit are consistent with those of the governing organization, or differences are justified by nursing education purposes. Commentary: The SSR, pp. 29-39, states that the nursing philosophy, purpose and objectives of the nursing program were developed to be congruent with the College mission and goals. Table 1-1 of the SSR p. 33 compares the College mission and goal statements with the nursing program s mission, philosophy, and program objectives. When interviewed, the interim President verified that there is congruence between the college and the program philosophies. Nursing faculty clarified the process used in developing their philosophy and how it is congruent with the Ancilla College philosophy. There was a committee consisting of Ancilla general education faculty, nurses, sisters, and lay people who developed the initial philosophy of the nursing program in 2004 prior to the programs existence. The current program philosophy has been revised with minor changes by the nursing director and faculty. The philosophy, purpose and program objectives are clearly stated and are consistent with contemporary beliefs of nursing. Commitment to cultural, racial, and ethnic diversity of the rural community is apparent in both the college mission and goals, and the nursing mission and philosophy. The organizational structure is clearly defined in the SSR pp 40-42. Table 2-1 depicts the organizational chart of the college and accurately demonstrates the reporting mechanisms. This was verified as accurate with the interim president. Additionally, Table 2-3 page 46 of the SSR accurately depicts the organizational chart for the nursing program. This was verified with the nursing program director. All full-time faculty or part-time faculty who teach at least 6 credits are voting members of the College Senate. Nursing faculty serve on college committees. Table 2-5 of the SSR p. 44 depicts nursing faculty participation on college committees 2004-2006. Table 2-4 SSR p. 49 depicts nursing faculty participation on nursing committees 2004-2006. Although Table 2-4 identifies faculty participation on an admission, curriculum, and other ad hoc committees, review of nursing program minutes reveal that all decisions of these committees are made as one group. It is clear to the PEs that as the nursing faculty group has expanded, that separate committee meetings will be necessary for effective decision-making. All students are voting members of the College Student Association. Table 2-5 p. 49 of the SSR reflects the student membership on nursing committees 2004-2006. Students participate in nursing committees and the Ancilla Student Nurses Organization (ASNO) as verified by review of SNO minutes and discussion with students. Students when interviewed felt they had opportunities for input. In addition to verbal discussion, students can offer suggestions in the classroom 126 suggestion box. Minutes from nursing faculty organization meetings do not reflect students attendance or participation. Ann Fitzgerald, the director, is academically qualified for the position. She has an MSN with a minor in Family Nurse Practitioner from Indiana University. She is licensed as a registered nurse in the state of Indiana and holds the American Academy of Nurse Practitioners certification as an advanced practice registered nurse. To further clarify Ms. Fitzgerald s educational experience discussed on p. 56 of the SSR, her CV was reviewed on-site by the PEs. According to Ms. Fitzgerald s CV, her experience has been primarily in nursing service. She was employed in areas as a nurse practitioner, community health nurse

and mid-level manager. She was adjunct faculty from August 2002 - March 2003 for Bethel College prior to her appointment as assistant professor of nursing/assistant program director. Ms. Fitzgerald s position description was reviewed and she has the authority and responsibility of the administration of the nursing program. She participates in the budgetary process of the college. This was verified by the interim president, the interim dean, the director herself, and the nursing faculty. Policies for nursing program faculty are consistent with policies for Ancilla College faculty. Policies are defined and described in the Ancilla College Faculty Handbook which was reviewed by the PEs. However, according to interviews with administrative personnel and nursing faculty, the Faculty College Handbook is being thoroughly reviewed/revised. The last documented date of review had been 1995. An example of a policy under revision is a proposal for elimination of the tenure process. This proposal has been submitted to the faculty senate for final decision. Nursing faculty and administrative personnel indicated that rank and promotion will remain in some form but are being reviewed and revised as well. The SSR page 75 discusses the nursing workload policy. The Ancilla College Faculty Handbook 2005 page 33 states that the teaching load for College faculty is defined in terms of credit hours. The reader is then referred to Section 2.11 for policies on faculty workload. However policy 2.11 discusses outside employment. The PEs are unclear on the college faculty workload policy. An Ancilla College full-time nursing faculty teaching contract is based on 27 contact hours of instruction per academic year. Faculty who have an assignment of over 27 hours are paid per overload hour. A review of faculty files revealed that all full-time nursing faculty had signed contracts for overload hours ranging from 3-10 hours. The differences for nursing faculty policies are justified and dictated by clinical agencies; for example CPR and immunizations are required. The nursing faculty are expected to demonstrate and maintain professional competency as displayed in faculty teaching portfolios.

Summary: Compliance: The Program is in compliance with the Standard. Faculty Standard: There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. Criteria: 5. Faculty members (full- and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. 6. Number and utilization of full- and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. 8. The collective talents of the faculty reflect scholarship through teaching, application, and the integration and discovery of knowledge as defined by the institution and the nursing education unit. Commentary: All faculty members, full and part time, are academically qualified for the position. There are 5 full time faculty members, including the Director. Four have MSN s and one faculty member is enrolled in a MSN program and will complete her degree in 2007. There are four part-time faculty, all have MSN degrees. There are 4 FNPs, 1 certified in women s health, 1 certified in OR, and 1 certified in adult health CNS. The faculty profile is documented on Table 5-1 page 71 of the SSR. PEs reviewed three sets of faculty files; the teaching portfolio for each faculty, the faculty files housed in the interim Dean s office and the faculty files provided to them in the reading room. All files contained a variety of inconsistent and often out-dated documents. According to the Faculty Handbook, the original educational transcripts are kept in the interim Dean s office files. Original or copies of transcripts were not available for review by the PE for some faculty members. Current RN licenses and CPR certifications were available in faculty files provided to the PEs in the reading room. All faculty have minimal experience in nursing education. Faculty educational qualifications are either in the area of Clinical Specialist or Nurse Practitioner. They have attended nursing education conferences and workshops but have not enrolled in formal nursing education courses. ISBON Annual Report 7/2012 Page 17

The number and utilization of full and part-time faculty currently meet the needs of the nursing program. The SSR page 78 states the faculty are evaluated on an annual basis and the faculty are expected to develop goals and objectives for the upcoming academic year. Not all faculty files contained self evaluations and evaluations completed by the nursing program director. For example, some faculty files had both, some had one or the other, and some had none. The evaluation form did not include an area for goal development and faculty confirmed that goals were not a part of this process. Nursing program minutes of 2/8/2006 reflect a plan that the Director will visit faculty members in the classroom and clinical prior to completing their March faculty evaluation. Faculty were asked to complete a self evaluation and update Faculty performance sheets by the end of February. Professional Portfolios were requested by the Director prior to the NLNAC visit. Students have an opportunity to evaluate faculty in both clinical and classroom. Data was available for review and was summarized in graph and chart forms. Students confirmed this process and indicated that this has led to positive program revision in terms of consistent care plan guidelines. Faculty demonstrate a strong foundation in clinical expertise. They are experts in the areas of their clinical teaching assignments. Students are very complimentary of the faculty expertise, clinical preparation, and familiarity with practice settings. CV s document a variety of clinical experiences. Although scholarship is not defined by Ancilla College, the nursing program has developed its own definition and is stated in the SSR page 82. Summary: Compliance: The Program is in compliance with the Standard with the following area needing development: Consistently follow the faculty evaluation process as described in the Ancilla College Faculty Handbook. ISBON Annual Report 7/2012 Page 18

Students Standard: The teaching and learning environment is conducive to student academic achievement. Criteria: 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. 11. Policies concerned with educational and financial records are established and followed. Commentary: Student policies for all Ancilla College students are consistent, publicly accessible, nondiscriminatory and consistently applied. The policies are discussed in the SSR pages 86-119 and are listed in the Ancilla College Handbook pages 11-34. Nursing students are required to have current CPR, appropriate immunizations, liability insurance, criminal background checks, and proof of an annual physical examination. Review of student files, kept in the nursing program office, show evidence of these requirements. Students have access to a variety of support services including but not limited to tutoring, Program Success, SOAR Program, counseling, financial aid, advisement and disability services. Interviews with students and support personnel verify that nursing students do access these services. Health Services are not available at Ancilla College. Policies regarding educational and financial records are established and followed. This was verified through interviews with the Registrar and Financial Aid officer. Summary: Compliance: The Program is in compliance with the Standard. ISBON Annual Report 7/2012 Page 19

Curriculum and Instruction Standard: The curriculum is designed to accomplish its educational and related purposes. Criteria: 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/ mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, values, and competencies necessary for nursing practice. 14. Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Commentary: The original Ancilla College curriculum was developed by a team of nurses, sisters and lay people interested in starting a nursing program for Ancilla College. Input was gleaned from the community concerning health care needs and wants as well as projections for future nursing needs on the state and local level. The curriculum was based on information provided by local hospitals, area nurses, the Indiana State Board of Nursing (ISBN) rules and regulations and student needs. The curriculum began in 2004 with 88 credit hours that was subsequently decreased to 72 credit hours to meet NLNAC guidelines. In the Fall of 2005, the Ancilla College nursing administrator and faculty began to review and revise the curriculum. Discussions with a consultant began August 4, 2005 according to the Nursing Program Department minutes. Additional faculty minutes, (9/22, 11/2, 11/22, 12/21, 1/11/06 and 2/8/06) document discussions among faculty in the areas of curriculum congruence, syllabi, philosophy statement and general preparation for the NLNAC site visit. Significant developments/revisions such as faculty bylaws, adoption of a policy/form for faculty record of professional development, nursing philosophy and organizing framework depiction, clinical course work/expectations/evaluations (N110), student handbook revision were completed as late as 2/8/06 per faculty minutes. The mission of the nursing program is depicted on page 121 of the SSR Table 12-1. The mission statement states that it was Inspired by the self-care nursing theory and incorporates a framework of six core curricular components. The philosophy states the nursing faculty have integrated the self-care deficit theory of Dorothea Orem and the six core concepts throughout the nursing program. Ancilla College nursing program core concepts are identified as caring, knowledge, critical thinking, clinical competence, communication and professionalism. After completing interviews with faculty and students to determine the foundation of the six core concepts, the PE are still unclear as to their origin. The SSR page 124, Table 12-2 compares the ASN Outcome Criteria with the ANA and NLN Professional Characteristics and Standards. The seven nursing courses are described in the SSR page 125-128. ISBON Annual Report 7/2012 Page 20

PEs reviewed each course syllabi on site. Syllabi were arranged in essentially the same format identifying the course description, academic core values, student learning outcomes, measures for student learning (total points for the course) grading system, and grading policies. Clinical experience expectations were not consistently addressed in each syllabi. The student learning outcomes (course objectives), were clear, demonstrated a logical progression, and flowed from the program objectives for NR 110, 210, and 211. Course objectives for NR 250 and NR 255 were content specific (OB/Peds, and Mental Health) and did flow from the program objectives. However, no mention was made of Orem s Self-Care deficit theory or constructs. When interviewed, faculty and students were confused regarding the six core concepts relation to Orem s Self-Care deficit theory. The N255 course syllabi states The case study will also reference Orem s 6 core concepts and how the case study advanced your preparation in one or more of these areas. After much inquiry, one faculty member was able to verbalizes that the six concepts were separate from Orem s theory. The Program director explained that Orem s theory was used to teach the students how to identify when nursing care is needed. There were no unit/content objectives for the courses. When asked, the nursing faculty and program director provided the PE with a calendar of each course which included topics, required readings, nursing concepts (one or more of the 6 core concepts), and some clinical and class assignments. The format for these calendars was not consistent. When interviewed, the faculty and the students indicated there were indeed no unit/content objectives. When asked how they prepared for class, exams and determined which content was important to know, students stated that instructors identified what content was important during the lectures. Students further stated that instructors may supply them with copies of their power point presentations which did help them in studying for exams. Clinical evaluations were reviewed for NR 110 and NR 210. NR 110 clinical evaluation tools that were completed for students from the class of 2006 and 2007 were reviewed. Students in the class of 2007 (1 st yr students) had one final clinical evaluation tool in their files which stated the course objectives, criteria for U/S for each objective, comments by the student, and total number of objectives met successfully and total number of objectives met unsuccessfully. The tool identified that the student must meet at least 75% of objectives successfully to pass the course (5). No critical behaviors were identified. Student and faculty signatures and dates as well as the Pass/Fail recommendation by faculty were identified on the back of the tool. Student files from the class of 2006 (second year students) were reviewed and showed that for NR 110, they had been evaluated after each clinical day using the same tool described above. NR 210 evaluation tools were confusing to the PEs, students and faculty. The scale on the tool identified A (Always) M (most of the time 80%), U (Unsatisfactory observed less than 80% of the time) and N/A (Not observed). Additionally, Satisfactory criteria stated that All observed critical objectives * must be A or M and 80% of all objectives observed must be A or M. When interviewed, students and faculty were unclear on the criteria for a student to earn an S or a U. The onsite clinical visit was at a local faith-based community hospital. The PE interviewed many of the hospital staff, the one student (three students called in sick) on the clinical medical-surgical unit and visited with 3 other students who were observing in CCU, OR and ER. The clinical section was from NR 210, which is the 2 nd nursing course in the 1 st year of the nursing program. The hospital nurse educator orients the students to the hospital and policies and was familiar with the hospital-college ISBON Annual Report 7/2012 Page 21

contract, student evaluations/feedback about the site, and the documentation of licensure of faculty. An open communication is apparent between college administration, faculty and the hospital. The one student was caring for one patient, administered medications, and provided care including assessment. The patient was one day post-op cholecystectomy. The staff nurse was aware of what the student would be doing for the day. No objectives or posted assignment were present. According to the faculty, students have one written final evaluation. Any other evaluation is conducted orally if/as needed. Clinical contracts for agencies were reviewed and found to be current. They identified specific responsibilities for the college and the agency, included termination clauses and were signed by both parties. The Ancilla College nursing program provides students with a variety of clinical experiences. The SSR pages 135-137 addresses the clinical areas utilized by the program. The PEs observed students clinical journals/paperwork and verified in discussions with students and faculty that many clinical hours were observational rather than hands-on. For example, in the OB/Peds course there were 18 hours of inhospital supervised clinical experience. There were 39 hours of student arranged clinical observational hours. Summary: Compliance: The Program is not in compliance with the Standard since Criterion 12 is not met, as evidenced by: Insufficient input into the curriculum by faculty. The organizing framework is unclear and not threaded throughout the curriculum. There is no logical progression of course outcomes to unit/content objectives. Inconsistent clinical evaluation tools and methodology. Resources Standard: Resources are sufficient to accomplish the nursing education unit purposes. Criteria: 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. 16. Program support services are sufficient for the operation of the nursing education unit. 17. Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. 18. Physical facilities are appropriate to support the purposes of the nursing education unit. ISBON Annual Report 7/2012 Page 22

Commentary: Fiscal resources are adequate to accomplish the program outcomes. Although the nursing program has a larger budget for salaries and continuing education, the remainder of the budget is in line with the other divisions in the college. The 2005-2006 budget reflects a significant increase in expenditures due to doubling of the nursing faculty including continuing education provided for them. The nursing faculty are all new to formal nursing education and therefore will be utilizing more continuing education dollars to expand their knowledge of curriculum development and program evaluation. Additionally, nursing faculty salaries are at a higher rate than that of the majority of faculty at Ancilla College. When interviewed, the interim President affirmed the budget as described in the SSR pages 142-146 and indicated continued support for faculty development money in the future. Nursing faculty also indicated that they were able to attend conferences and in-services related to improving their teaching skills. Program support services and learning resources are adequate to support the nursing program. The library was visited by the PE and the librarian was interviewed. It was verified that learning resources available to students and faculty on-line and on site were adequate and as described in the SSR. Physical facilities are adequate and as described in the SSR. Although faculty share office space, conference rooms are readily available for private, individual student conferences. The Nursing Resource Lab was visited by the PE. The Program Director indicated that some of the equipment was donated by area hospitals, primarily St. Joseph s and LaPorte. Students verified the lab hour access and availability. A second level nursing student was employed as a work-study student to be available to assist nursing students in utilizing the lab. Classroom space was deemed adequate with the availability of appropriate up-to-date technology. Summary: Compliance: The Program is in compliance with the Standard. Integrity Standard: Integrity is evident in the practices and relationships of the nursing education unit. Criteria: 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. 20. Complaints about the program are addressed and records are maintained and available for review. ISBON Annual Report 7/2012 Page 23

21. Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. Commentary: Some published documents available to the general public and prospective students are clear, current, accurate and consistent. The 2004-2006 College catalog was available on site and in print. The Ancilla College catalog 2006-2007 is in its final stage of revision at this time. The PE evaluators reviewed this document and found that the nursing course clock to credit hour ratios were absent in most course descriptions and absent from the curriculum plan described on pages 60-62. Inconsistencies in nursing program information were discovered. Tuition and fees as published in the catalog page 27 were verified as inaccurate with the Program Director. The Nursing Program student handbook has recently been revised and is accessible on the nursing web site. There are some inconsistencies in the Nursing Student Handbook. The six core concepts are identified as the framework for the program. No mention is made of Orem s Self Care Deficit Theory. Additionally, page 5 of the handbook describes the 1990 NLN Roles of the AD Nurse as outcome criteria utilized by the program. There is no mention of this criteria anywhere else in the program documents. The admission process is clear and consistent in all documentation. The nursing web site was accessed and reviewed by the PEs. The information was correct, but again, the course clock to credit hours were omitted. The College student handbook is under revision at the current time. Complaints are defined by the program as issues that have reached the level of the formal grievance process. At present, no formal complaints have been filed. Student issues are dealt with in an ongoing manner and are usually resolved quickly due to faculty and Director availability. The institution has a written comprehensive program to promote student loan repayment that addresses: student loan information, counseling, monitoring and cooperation with lenders. This was verified with the director of financial aid. Based on the review of these documents, the team concludes that the nursing unit is in compliance with the higher Education Authorization Act. Summary: Compliance: The Program is not in compliance with the Standard as Criterion 19 is not met, as evidenced by: Information about the program intended to inform the general public, prospective students, current students, employers and other interested parties is not current, accurate, clear, and consistent. Educational Effectiveness ISBON Annual Report 7/2012 Page 24

Standard: There is an identified plan for systematic evaluation including assessment of student academic achievement. Criteria: 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. 23. Student academic achievement by program type is evaluated by: graduation rates, licensure/ certification pass rates, job placement rates, and program satisfaction. Commentary: There is a written plan for systematic program evaluation (SPE) and assessment of outcomes. The plan is identified with each Standard and Criteria throughout the SSR. The plan includes: the operational definition and expected level of achievement (ELA), the component, document location, person responsible, frequency of assessment, assessment method, degree of reliability, validity and trustworthiness, results of data collection and analysis and actions for program development, maintenance and revision. The ELA s documented under each criteria are not consistently measurable. For example Criterion 1, Table 1-2 page 37 of the SSR states the ELA: The Division of nursing will maintain philosophy, goals, objectives, bylaws, and organizational structure congruent with Ancilla College. Criterion 2 Table 2-6 page 53 of the SSR states the ELA Nursing faculty will be actively involved with the Ancilla College Senate. Additionally, the SPE does not reflect the aggregated and trended data used in decision making for the development, revision or maintenance of the program. For example, although the program has only been in existence for three semesters, the clinical evaluation tool for one course has been revised twice. Many changes have been implemented or in process on a continuous basis throughout the past year without discussion or systematic evaluation. Faculty are enthusiastic about learning and have attended educational conferences that have sparked new ideas. As a result of this, the ideas are implemented without systematic planning and evaluation in terms of the effect it will have on the entire program. There has been no time to adequately evaluate the process before it is revised. In other words, the program is in a constant state of change. Although there have been no graduates from the program, Table 23-1 page 187-188 of the SSR lists the ELA s for student academic achievement that will be measured. These ELA s are stated in measurable terms. Additionally, a calendar for implementation of the SPE for the nursing program is listed on page 190 of the SSR. Summary: Compliance: The Program is not in compliance with the Standard as Criterion 22 is not met, as evidenced by: ISBON Annual Report 7/2012 Page 25